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Personal and Emergency Contact Information
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Fields marked with an * are required
Student Information
Non Clarke Email Address *
Student Type*
Undergraduate (seeking Bachelor degree)
Graduate (seeking post Bachelor degree)
First Name *
Middle Name
Last Name *
Birthdate *
Birthdate *
January
February
March
April
May
June
July
August
September
October
November
December
1
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31
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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2000
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1991
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1982
1981
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1971
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1967
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1963
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1961
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Cell Phone *
Are you a commuter? *
Are you a commuter? *
Commuter
Live on Campus
Local Address *
Local Address *
Country
Street
City
Region
Postal Code
Mailing Address *
Mailing Address *
Country
Street
City
Region
Postal Code
Personal Information
Height *
Weight *
Hair Color *
Gender *
Race/Ethnicity Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to respond to the following two questions
Are you a Hispanic or Latino ? *
Are you a Hispanic or Latino ? *
Yes
No
Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:
Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
White
Religion
Atheist
Baptist
Christian
Jewish
Lutheran
Lutheran ELCA
Lutheran Missouri Synod
Lutheran Wisconsin Synod
Methodist
Mormon
Muslim
Non-Denominational
None
Other
Pentecostal
Presbyterian
Protestant
Roman Catholic
United Church of Christ
Married *
Married *
Yes
No
Emergency Contact
Please list your emergency contact(s). This data will be used to provide contact information in the event of an emergency. Please list the contacts in the order you want them to be notified if an emergency arises. Clarke University will call those in the order listed until a person is reached.
Relation to student *
Mother
Father
Step-Mother
Step-Father
Legal Guardian
Aunt
Uncle
Grandmother
Grandfather
Sister
Brother
Spouse or Partner
Son
Daughter
Other
First Name *
Last Name *
Phone *
Email Address *
Should this person be contacted in the event of an emergency? *
Should this person be contacted in the event of an emergency? *
Yes
No
In case of serious illness or accident, do you want a priest/clergyman to be called? *
In case of serious illness or accident, do you want a priest/clergyman to be called? *
Yes
No
Add an additional Authorized Individual? *
Add an additional Authorized Individual? *
Yes
No
Relationship *
Mother
Father
Step-Mother
Step-Father
Legal Guardian
Aunt
Uncle
Grandmother
Grandfather
Sister
Brother
Spouse or Partner
Son
Daughter
Other
First Name *
Last Name *
Phone *
Email Address *
Should this person be contacted in the event of an emergency? *
Should this person be contacted in the event of an emergency? *
Yes
No
In case of serious illness or accident, do you want a priest/clergyman to be called? *
In case of serious illness or accident, do you want a priest/clergyman to be called? *
Yes
No
Add an additional Authorized Individual? *
Add an additional Authorized Individual? *
Yes
No
Relationship *
Mother
Father
Step-Mother
Step-Father
Legal Guardian
Aunt
Uncle
Grandmother
Grandfather
Sister
Brother
Spouse or Partner
Son
Daughter
Other
First Name *
Last Name *
Phone *
Email Address *
Should this person be contacted in the event of an emergency? *
Should this person be contacted in the event of an emergency? *
Yes
No
In case of serious illness or accident, do you want a priest/clergyman to be called? *
In case of serious illness or accident, do you want a priest/clergyman to be called? *
Yes
No
Medical Information
List any Medications to which you are allergic - separated by commas *
List any chronic illnesses - separated by commas *
List any medication(s) you take on a regular basis - separated by commas *
Insurance Company *
Policy Number *
Thank you for providing this information. If you need to make any changes or updates, please contact the Student Life Office at (563)588-6313
Submit